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Risk Management and Assessment
The problems of engaging men, especially angry and aggressive men, are well known in health services. The first part of this paper addresses why it is that some men behave in aggressive and/or antisocial ways, and how the beliefs of mental health service workers about these men may contribute to their marginalization. The second part of the paper is a case study outlining a successful therapy intervention with a man who displayed very aggressive behaviors; this case study highlights some of the issues that needed to be addressed to achieve this positive outcome. For this paper, a traditional male is defined as one who expresses values and behaviors such as being emotionally stoic and denying vulnerability, highly valuing work, status, achievement and success, being forceful and aggressive as an interpersonal style, and rejecting anything associated with femininity as part of the male role. These values and behaviors are associated with high levels of risk-taking behaviors, substance usage and violence and contribute to high levels of mental illness and successful suicides in men.
Issues affecting traditional men
One of the major outcomes of childhood abuse and neglect seems to be a failure to learn how to modulate emotions. The individual has an inability to experience and label their emotions that increases the likelihood of emotional avoidance. As a consequence, the problem or situation related to the emotion cannot be attended to, thus increasing the likelihood of repeated difficulties.
Development of self-regulation abilities related to physiological arousal and associated behaviors when experiencing strong affect is not achieved. This includes an inability to refocus attention when dealing with strong affect that makes the achievement of external, nonmood- dependent goals very difficult if not impossible. Thus, the individual lives in the present heavily determined by the strong affect of the moment. Furthermore, as Brooks describes, ‘In many ways traditional men in general seem to be continually susceptible to the powerful and potentially destructive emotions of anger, bitterness, and frustration’. Indeed, for some men, anger becomes the major form of emotional expression.
This anger can lead some men to behave in antisocial ways that brings them into conflict with the law. If they then also present to a mental health service they are often characterized as antisocial and/or having an antisocial personality disorder. As there is a long history within psychiatry of seeing ASPD as being unresponsive to treatment, such men are often sent away without any offer of treatment in the belief that their problems really fall within the auspices of the criminal justice system.
Little regard is given to the level of trauma these men may have experienced in childhood, and in the process of establishing their masculinity, and whether their behavior is part of a process of continuing retraumatization. In addition, there is no differentiation between antisocial behavior and antisocial personality traits in the 4th edition of the Diagnostic and Statistical Manual-IV. In this paper, we are not wishing to address all men diagnosed as having an antisocial personality disorder. Rather, this paper is concerned with those men who have experienced trauma during their formative years and are at the less severe end of the continuum of behavioral and symptomatic severity.
These consequences of trauma have been well documented in the literature associated with borderline personality disorder but not to the same extent in the literature associated with antisocial personality disorder (ASPD). However, there are many similarities between BPD and ASPD. There is a similarity in the frequency with which both ASPD and BPD occur within populations. ASPD, which is well studied, has a frequency of 2.4–3.7% of the population. BPD, which has been the subject of very few population studies, occurs in approximately 2% of the population. There are suggestions both are increasing in prevalence. ASPD and BPD exhibit several common traits: both have family dysfunction as a major risk factor; impulsive behaviors are common to both; relationships are often labile in both with a sensitivity to rejection; both have changed seretonin activity as a possible biological marker; and both have a similar course over time with probable burnout by 40.
Serious substance abuse is associated with both ASPD and BPD. If begun in adolescence and continued into adult life, substance abuse may continue the cycle of retraumatization. It may diminish the individual’s ability to judge situations and/or engage in self-protective behavior. Individuals under the influence of substances are often disinhibited and, thus, more likely to be impulsive.
In frequenting places where substances are available, the individual may be in contact with impulsive and/or violent people. As evidenced by the strong gender groupings in the diagnosis of ASPD and BPD, there are some biases underlying the utilization of these diagnoses. Taking a broad view, there are issues of class and wealth and their effect on whether behavior is perceived as antisocial or a temporary aberration. When males are being assessed, there tends to be an overemphasis on their criminal history and an underemphasis on their dependent/needy features. When females are assessed there tends to be an underemphasis on their antisocial/violent features. It has been estimated that 25% or more of individuals diagnosed with either ASPD or BPD meet the criteria for both diagnoses.
Additionally, the comorbidity with substance abuse affects the rate of diagnosis. Many behaviors and situations, which result from being under the influence of a substance, become attributed to ASPD or BPD. Dinwiddie and Reich (1993) found that the rate of diagnosis of ASPD in a substance-abusing population dropped substantially when behaviors related to substance abuse were excluded.
The expression of anger and aggression is believed by some to have a gender basis, and that this accounts for the gender dominance in the diagnosis of BPD and ASPD. It is believed boys and men tend to externalize anger while girls and women tend to internalize aggression, and that this is the basis of the differing symptoms evident in ASPD and BPD. Hatzitaskos et al. (1997) found this to be true for a population of 85 young male patients (44 ASPD and 41 BPD). They found the ASPD patients had more extroverted hostility, the BPD patients had more introverted hostility, and that hostility plays an important role in the development of symptoms. That these results were obtained within a single-sex study would tend to undermine the proposition that gender dominance in the diagnosis of BPD and ASPD is related to gender-based expression of anger and aggression. Rather, it would tend to underline the following statement by Paris (1997) that, ‘If it were not inconsistent with clinical tradition, we could have described a single gender-neutral disorder that covers the present ground traversed by the criteria for ASPD and BPD’.
Treatment within the mental health system for individuals with a background of trauma could probably be best characterized by the following statement from Herman: that, traumatized people are frequently misdiagnosed and mistreated in the mental health system. Because of then number and complexity of their symptoms, their treatment is often fragmented and incomplete. Because of their characteristic difficulties with close relationships, they are vulnerable to become re-victimized by caregivers. They may become engaged in ongoing, destructive interactions, in which the medical system replicates the behavior of the abusive family. There is a long-held belief within psychiatry that all forms of treatment for ASPD are unsuccessful. Current literature reports a dismal picture with statements such as ‘virtually all methods of treatment with antisocial patients are likely to fail’ (Paris 1997), ‘antisocials are a nuisance on inpatient units’ (Black 1999), and ‘Probably the only consensus on treating ASPD is that it is difficult to treat’ (Kaylor 1999). However, we might ask whether what is really being reflected here is the failure of ‘the treatment’ offered to address the needs of a very vulnerable group of clients. Recent research in men’s health may provide much needed illumination in this area. Brooks (1998) writes about the culture associated with traditional masculine values and how the demands of hospitalization and psychotherapy can be diametrically opposed to these. Psychotherapy and hospitalization require the individual to disclose private experiences, relinquish control, express feelings, acknowledge failure, and admit to ignorance. The traditional values of many males demand they hide private experience, maintain control, be stoic, endlessly persist even when things aren’t working out, and feign omniscience (no matter how bad things are). To be seen to do otherwise is a great source of shame for these men. This shame is often of sufficient magnitude to override any impulse to seek help. Thus, it is that men who have traditional values and a diagnosis of ASPD seem to confirm there is no point in offering individuals with ASPD treatment.
In contrast, BPD is seen as having some treatment possibilities even though there are considerable difficulties to surmount. There are two evidenced-based approaches to the treatment of BPD. These are the ‘interpersonal– psychodynamic psychotherapy (IP)’ approach of Meares et al. (1999), and the Dialectical Behavior Therapy (DBT) approach of Linehan (1993). Although the therapies utilized in these approaches are different, the client outcomes have been similar in studies where both therapies were compared with ‘treatment as usual’.
When one looks past the style of therapy and considers the structure of the overall treatment program, the similarities become apparent. Both programs are about 1 year in length with the client being seen twice weekly. In IP, an individual therapist sees the client twice weekly, whereas in DBT, the client is seen weekly by an individual therapist and also attends weekly skills training in a group format. In IP, the therapist has weekly individual supervision and separate weekly didactic input as part of a training program. In DBT, the therapist has supervision and didactic input as part of a weekly supervision group.
It is possible the structure surrounding the therapy provides containment for both client and therapist; providing for the maintenance of therapist hope and maintaining goal-directed treatment in the face of slow change and high levels of distress. It may well be it is the provision of this structure that allows these different therapies to attain similar results.
Given the availability of recent evidence supporting positive treatment outcomes for BPD, and the similarities between BPD and ASPD, it would seem timely to rethink treatment approaches to ASPD. It may be possible to provide structured treatment approaches which take into account the traditional values many men have, allowing them to utilize the treatments effectively.
-Stewart, Don; Harmon, Karen. International Journal of Mental Health Nursing (2004)
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